P - 83037REGIUEST FOR ELECTRICAL INSPECTION �
� � � � �I 0 � � Minnesota State Board of Electricity _
� �'f 1821 University Ave., Rm. S-128, St. Paul, MN 55104
�
Phone (612) 642-0800 '�'
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Re air
Air Con Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elec. Heat - Temp. Service
"X" above fhe work covered by fhis request. Enfer remarks in this space and on the back of the white copy only.
,�.�� �c � ���
Calculate Inspection Fee - This Inspection Request will o e accepted without fhe correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stoll 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTAL
Sign/Oudine Ltg. Xfmr. cS�
Alarm/Remofe Conhol
Swimming Pool
I hereb certi that I ins ted fhe elechical installafion described herein on ihe dafes stafed
Irrigation Boom Rough-I� Dare
Speciallnspecti ' �
Final �
Investigative Fee '
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFICE USE ONLY This requesf void 18 monfhs from validafion dafe prinfed in this box.
(�I�OI�I��I�I��N�1��1�I���O���UI��� s ��:�
* 0 6 8 2 4 0 7 2� �L.� 7s
PLEASE PRINT OR TYPE
Request Date Rou h-in ins ion r uiredZ ❑ Yes
g pecf' eq ❑ No Inspecfion O�er Than Rough-In: Ready Now ❑ Will Call
��/ " � �You musf wll the inspecfor when ready� Date Ready:
I, icensed contractor ❑ owner hereby re uest inspection of the above electrical work at:
Job ddress (Sfreet, Box, or R ie :� s. City Zip Code
�1�✓ �i� J / J .
� Secfion No. Towns ip Name or No. Range No. Fire No. � County � �
��� � Phone No.
C�2i S �"7� ^S��a
Power Supplier /� � Address
Elecirical Conhacfor (Company Name) Conhactor License No. Masfer Lic. No. (Planf Elecf. Only
DEPENDABLE E���TRIC, INC. �3� C ���
� , � �5rourn�o��
��an Rapids. MN 55 3
Aufhorized Signalure (Conk r Owner PerForming Ins Ila on� _: Phone No.
- 7s?-s��
E&0000 11 8/96 y� � qpD COPY - SEE INSTRUCTIONS ON BACK OP YELLOW COPY